Nephrologist Jean Holley, MD, will never forget Deena and Mary (not their real names), two patients with end-stage renal disease (ESRD) she cared for 20 years ago who asked her to let them die. Deena, a widow in her 70s, had been on hemodialysis for eight years. Mary, who was in her late 40s and severely diabetic, needed to begin dialysis immediately to survive. Deena wanted to stop dialysis; Mary did not want to start. In both cases, refusal would almost certainly lead to death in less than a month.

NEW YORK—Despite many advances over the years, dialysis and transplantation remain imperfect solutions to renal replacement. One of every five dialysis patients dies every year, and the shortage of live and cadaver donor organs shows no sign of ending or even abating.

"My wife says the only time she realizes I'm retired is on payday," said James E. Cimino, MD, one recent morning, glancing down at his Mickey Mouse watch to make sure he was on schedule. Although he officially retired from his position as director of the Palliative Care Institute at Calvary Hospital in the Bronx in 2003, Dr. Cimino, 78, is lively, engaged, and continues to meet regularly with medical students and work on special projects.